Cognitive Behavioural Therapy

This leaflet is for anyone who wants to know more about
Cognitive Behavioural Therapy (CBT). It discusses how it works, why it is used,
its effects, its side-effects, and alternative treatments. If you
can't find what you want here, there are sources of further
information at the end of this leaflet.

What is CBT?

It is a way of talking about:

how you think about yourself, the world and other people

how what you do affects your thoughts and feelings.

CBT can help you to change how you think ('Cognitive') and
what you do ('Behaviour'). These changes can help you to feel
better. Unlike some of the other talking treatments, it focuses on
the 'here and now' problems and difficulties. Instead of focusing
on the causes of your distress or symptoms in the past, it looks
for ways to improve your state of mind now.

When does CBT help?

CBT has been shown to help with many different types of
problems. These include: anxiety, depression, panic, phobias
(including agoraphobia and social phobia), stress, bulimia,
obsessive compulsive disorder, post-traumatic stress disorder,
bipolar disorder and psychosis. CBT may also help if you have
difficulties with anger, a low opinion of yourself or physical
health problems, like pain or fatigue.

How does it work?

CBT can help you to make sense of overwhelming problems by
breaking them down into smaller parts. This makes it easier to see
how they are connected and how they affect you. These parts
are:

ASituation - a problem,
event or difficult situation. From this can follow:

Thoughts

Emotions

Physical feelings

Actions

Each of these areas can affect the others. How you think about
a problem can affect how you feel physically and emotionally.

There are helpful and unhelpful ways of reacting to most
situations, depending on how you think about it. The way you think
can be helpful - or unhelpful.

An example:

The Situation

You've had a bad day, feel fed up, so go out shopping. As you
walk down the road, someone you know walks by and, apparently,
ignores you. This starts a cascade of:

Unhelpful

Helpful

Thoughts:

He/she ignored me - they don't like me

He/she looks a bit wrapped up in themselves - I wonder
if there's something wrong?

Emotional:
Feelings

Low, sad and rejected

Concerned for the other person,
positive

Physical:

Stomach cramps, low energy, feel sick

None - feel comfortable

Action:

Go home and avoid them

Get in touch to make sure they're OK

The same situation has led to two very different results,
depending on how you thought about the situation.

How you think has affected how you
felt and what you did. In the
example in the left hand column, you've jumped to a conclusion
without very much evidence for it - and this matters, because it's
led to:

having a number of uncomfortable feelings

behaving in a way that makes you feel worse.

If you go home feeling depressed, you'll probably brood on
what has happened and feel worse. If you get in touch with the
other person, there's a good chance you'll feel better about
yourself.

If you avoid the other person, you won't be able to correct
any misunderstandings about what they think of you - and you will
probably feel worse.

This 'vicious circle' can make you feel worse. It can even
create new situations that make you feel worse. You can start to
believe quite unrealistic (and unpleasant) things about yourself.
This happens because, when we are distressed, we are more likely to
jump to conclusions and to interpret things in extreme and
unhelpful ways.

CBT can help you to break this vicious circle of altered
thinking, feelings and behaviour. When you see the parts of the
sequence clearly, you can change them - and so change the way you
feel. CBT aims to get you to a point where you can 'do it
yourself', and work out your own ways of tackling these
problems.

What does CBT involve?

The sessions
You can do CBT individually or with a group of people, or even
a self-help book or computer programme.

In England and Wales, two computer-based programmes have been
approved for use by the NHS. Fear
Fighter is for people with phobias or panic
attacks; Beating the Blues is for
people with mild to moderate depression.

If you have individual therapy:

You will usually meet with a therapist for between 5 and 20,
weekly, or fortnightly sessions. Each session will last between 30
and 60 minutes.

In the first 2-4 sessions, the therapist will check that you
can use this sort of treatment and you will check that you feel
comfortable with it.

The therapist will also ask you questions about your past life
and background. Although CBT concentrates on the here and now, at
times you may need to talk about the past to understand how it is
affecting you now.

You decide what you want to deal with in the short, medium and
long term.

You and the therapist will usually start by agreeing on what to
discuss that day.

The work

With the therapist, you break each problem down into its
separate parts, as in the example above. To help this process, your
therapist may ask you to keep a diary. This will help you to
identify your individual patterns of thoughts, emotions, bodily
feelings and actions.

Together you will look at your thoughts, feelings and
behaviours to work out:

if they are unrealistic or unhelpful

how they affect each other, and you.

The therapist will then help you to work out how to change
unhelpful thoughts and behaviours.

It's easy to talk about doing something, much harder to
actually do it. So, after you have identified what you can change,
your therapist will recommend 'homework' - you practise these
changes in your everyday life. Depending on the situation, you
might start to:

question a self-critical or upsetting thought and replace it
with a more helpful (and more realistic) one that you
have developed in CBT

recognise that you are about to do something that will make you
feel worse and, instead, do something more helpful.

At each meeting you discuss how you've got on since the last
session. Your therapist can help with suggestions if any of the
tasks seem too hard or don't seem to be helping.

They will not ask you to do things you don't want to do - you
decide the pace of the treatment and what you will and won't try.
The strength of CBT is that you can continue to practise and
develop your skills even after the sessions have finished. This
makes it less likely that your symptoms or problems will
return.

How effective is CBT?

It is one of the most effective treatments for conditions where
anxiety or depression is the main problem.

It is the most effective psychological treatment for moderate
and severe depression.

It is as effective as antidepressants for many types of
depression.

What other treatments are there and how do they
compare?

CBT is used in many conditions, so it isn't possible to list
them all in this leaflet. We will look at alternatives to the most
common problems - anxiety and depression.

CBT isn't for everyone. Another type of talking treatment may
work better for you.

CBT works as well as antidepressants for many forms
of depression. It may be slightly better than antidepressants
in helping anxiety.

For severe depression, CBT should be used with antidepressant
medication. When you are very low, you may find it hard to change
the way you think until the antidepressants have started to make
you feel better.

Tranquillisers should not be used as a long term treatment for
anxiety. CBT is a better option.

Problems with CBT

CBT is not a quick fix. A therapist is like a personal trainer
that advises and encourages - but cannot 'do' it for you.

If you are feeling low, it can be difficult to concentrate and
get motivated.

To overcome anxiety, you need to confront it. This may lead you
to feel more anxious for a short time.

A good therapist will pace your sessions. You decide what you
do together, so you stay in control.

How long will it last?

A course may be from 6 weeks to 6 months. It will depend on
the type of problem and how it is working for you. The availability
of CBT varies between different areas and there may be a waiting
list for treatment.

What if the symptoms come back?

There is always a risk that the anxiety or depression will
return. If they do, your CBT skills should make it easier for you
to control them. So, it is important to keep practising your CBT
skills, even after you are feeling better. There is some research
that suggests CBT may be better than antidepressants at preventing
depression coming back. If necessary, you can have a "refresher"
course.

So what impact would CBT have on my life?

Depression and anxiety are unpleasant. They can seriously
affect your ability to work and enjoy life. CBT can help you to
control the symptoms. It is unlikely to have a negative effect on
your life, apart from the time you need to give up to do it.

How can I get CBT?

Speak to your GP. They may refer you to someone trained in CBT
- for example, a psychologist, nurse, social worker or
psychiatrist.

Useful CBT web links

Further reading

Reading Well Books on Prescription helps you manage your
well-being using self-help reading. The scheme is endorsed by
health professionals, including the Royal College of Psychiatrists,
and is supported by public libraries.

Self-help books which use the theories and concepts of
CBT to help people overcome many common problems. Titles include:
overcoming social anxiety and shyness, overcoming depression and
overcoming low self-esteem.

Free online CBT resources

Living Life to the
Full: Free online life skills course for people
feeling distressed and their carers. Helps you understand why
you feel as you do and make changes in your thinking, activities,
sleep and relationships.

FearFighter: free
access can only be prescribed by your doctor in England and
Wales.